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TRANSCRIPT
We’ve got work to do
for better mental health
Transforming employment and back-to-work support for people with mental health problems
December 2014
3
ForewordDuring the eight years I have been CEO of Mind, the issue of work and mental health has been continually rising up the agenda of politicians, employers and health services. There has been increasing recognition that more needs to be done to help people stay well at work, to avoid people falling out of work because of mental health problems, and to support people who are out of work because of their mental health to move closer to employment.
The attention paid to this vital area has been very welcome, and has undoubtedly led to improvements in how people with mental health problems are supported in a range of situations. However, the scale and pace of change has been nowhere near sufficient: the
majority of workplaces are still not taking the mental wellbeing of staff seriously enough; huge numbers of people continue to fall out of work because they are experiencing a mental health problem but not getting the support they need; and too few people with mental health problems are being helped back into work.
As we near the next General Election and the start of a new Parliament, there is a welcome opportunity for political and public debate to zoom out and look at the bigger picture, learn from what has gone before, and develop bold plans for creating a more positive future. I firmly believe that addressing issues around mental health and employment will be one of the key challenges that the next Government will need to get to grips with.
Because of the prevalence of mental health problems in the context of work, benefits and back-to-work support, the case for action is indisputable. Policy makers should conclude, as we have, that if the process of in-work, out-of-work and back-to-work support for people with disabilities does not work for mental health, then it simply isn’t working.
• Mental health is the leading cause of sickness absence in the UK, with 70m sick days in 2013.1
• Over a third of people with mild to moderate mental health problems, and almost two thirds of people with more severe mental health problems are unemployed.2
• Almost half of people receiving Employment and Support Allowance are claiming primarily because of mental health problems.3
This all leads to a cost to the UK economy, through sickness absence, lost productivity, and benefits expenditure, of £70–£100 billion per year.4 Even more importantly, from Mind’s perspective, it means that hundreds of thousands of people are finding it harder to recover from their mental health problems because they are not getting the support they need.
With such clear rewards for getting this right, why hasn’t it been fixed already? With the increased attention this area of policy has been receiving, there has been no shortage of discussions, conferences, policy documents and government announcements. While these interventions have often made a useful contribution to the debate, they have failed to grasp the scale of the challenge and propose reform that is sufficiently ambitious to address it.
This report brings together years of Mind’s work in this area to explain how and why the workplace, the benefits system, and back-to-work schemes are so often failing to provide the support that people with mental health problems need to stay in, return to, or start work. We have set out our vision of what needs to be done to create a system that works. This vision is bold and ambitious, and will not be easy to achieve. But it is a vision the next Government will need to realise if it is to address this vital issue, and improve the lives of millions of people.
Paul FarmerChief Executive, Mind
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Imagine for a moment…Something’s changed. You don’t feel like yourself anymore. You have trouble sleeping. Negative thoughts keep going round and round in your head, making you feel anxious. You struggle to concentrate on things and you feel low all the time.
The job you once enjoyed is now overwhelming. You’ve been there three years, been promoted twice and are responsible for a team of people. What would they say if they knew how you felt? The last time someone admitted they had a mental health problem they were quietly forced out.
You try to seek help but find out you’ll have to wait months to see a counsellor. Work is going downhill. You start having to take days off for ‘flu’ just to cope. To make it worse, no-one seems to notice how bad you’re feeling.
Finally, you tell your manager how you feel. They seem sympathetic, if a little awkward, and suggest some time off work. In the six weeks you’re off, your manager calls only once. When you return to work there’s no support in place. Things go from bad to worse. You feel you have no option but to leave your job.
Weeks pass. There’s no sign of the counselling. You desperately want to get back into work, but you’re just not well enough. Your savings are dwindling and the bills are piling up. You know you have no other choice, you’re going to have to ask for support. You sheepishly head down to your nearest jobcentre to talk to someone to explain what’s happening. You expect support (and perhaps a little compassion), but instead all the focus is on what you need to do to get and continue receiving benefits. What you thought would be a positive step forward has only made you feel worse and you slip further into depression.
There is some hope though. You’ve been told there’s a special type of support for people with disabilities and health conditions. This sounds promising. But then you get asked to go to an assessment to prove you’re unwell.
Trying to explain what’s going on in your head to your partner, family and friends is hard enough, never mind telling a complete stranger.
At the assessment, the questions you’re asked don’t allow you to explain why your mental health makes it hard for you to work. There’s no discussion about the support that could help you recover and get back into work.
You don’t feel trusted or understood. It all seems to be about making a black and white decision about whether you should get benefits.
Thankfully you are granted benefits on the condition you attend a scheme to help you return to work. You’re hopeful about the scheme but worry about losing your benefits if you struggle to take part because of your illness.
You meet an advisor who says you need to attend CV writing classes and group workshops on positive workplace behaviour. You find this confusing. You held down a job for years, you want to work and you know how to get a job. It’s your mental health problem that’s making things difficult.
The classes and workshops don’t tell you anything you don’t already know. After a couple of weeks you start to think, “This is actually making me feel worse.” You feel like you’re wasting your time, but the threat of losing benefits means you have to attend.
One morning you feel so anxious, you can’t face leaving the house let alone spending time in a class with people who don’t understand how ill you are. No-one asks how you are but instead your benefits are stopped and you have to start the process over again.
With no support to help you get better and overcome the challenges you’d face going back to work, you feel like there’s no way out. It feels like they’ve forgotten that you’re in this situation because you’re unwell, not because you don’t know how, or want to work. It just doesn’t seem right.
Things need to change.
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IntroductionThe story you’ve just read is about a journey experienced by hundreds of thousands of people with mental health problems across the country. Thousands of them have spoken to us about this journey and the same issues arise again and again. This report is about the challenges they’ve faced in work, with the benefits system, and with back-to-work support.
Over the last five years, Mind has been working on each stage of this journey. We have been listening to the people we represent, hearing from services supporting people at the frontline, analysing the evidence of what is and isn’t working, and engaging with Government, providers and employers to shape how policies and services are designed and delivered.
We have reached the conclusion that, whilst there have been improvements to some parts of the journey, they have not been sufficient to make a real difference to the lives of people with mental health problems. Much wider and more fundamental reforms are needed. They need to be designed and delivered with an understanding of the whole journey and how people experience it.
Reforms need to begin by understanding what it’s like to experience a mental health problem and why this can make it difficult to work. Based on this, support for people experiencing a mental health problem in work needs to improve, so that more people can remain in employment. Workplaces that are more mentally healthy will benefit all staff and will be more receptive and appropriate for people with mental health problems moving into work.
When people do fall out of work because of their mental health, they need to be supported and understood by the benefits system and, where appropriate, directed towards effective back-to-work schemes.
Current government back-to-work schemes are failing people with mental health problems because they are not built on a proper understanding of why people
have ended up out of work and what support they will need to move closer to work.
Appropriate work, combined with the right support, is good for people’s mental health. For many people who are out of work because of a mental health problem, a return to employment will be a key part of their recovery. However, too often, the objective of moving people into work is used to justify a ‘tough’ approach of making benefits conditional on people engaging in back-to-work activities. This approach is proving ineffective and often inappropriate. Only a tiny minority find work and many report that their mental health, confidence, and ability to work decline even further.
Most people with mental health problems want to be in work but need support to overcome the barriers they face – being listened to and understood, managing their health condition, improving their confidence, gaining new skills, and being in an appropriate job with the right support.
We believe, by building a system that understands this, many more people can be helped to stay in, return to, or begin work. However, this won’t be achieved by tweaking the current system. We need fundamental reform that addresses the false assumptions and lack of understanding about mental health that currently hinders the progress of so many people, and instead provide the support people with mental health problems want and need.
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This report describes the journey that so many people are experiencing and explains what is going wrong at each stage. It sets out what needs to be done to create a system that works.
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Recommendations
Better in-work support
1. Employers need to do more to promote wellbeing in the workplace and support people with mental health problems to stay in work, following the lead of those who have signed up to Time to Change or joined such campaigns as Business in the Community (BITC) or City Alliance.
2. The next Government must do more to promote better in-work support to employers, which includes:
• expanding on current schemes such as Disability Confident
• promoting schemes that recognise the work of good employers
• continuing to support the Time to Change campaign to tackle stigma and discrimination
• reforming the Government’s Two Ticks scheme
• ensuring SMEs are supported to provide comprehensive in-work support.
3. The next Government should improve its own in-work support offer to people with mental health problems who are at risk of falling out of work.
• Access to Work should be better promoted and made more accessible for people with mental health problems and should aim to direct at least 10 per cent of the budget towards this group.
• The new Fit for Work service should retain its person-centred approach to supporting people during sickness absence but must also effectively engage employers in the process.
A fair and responsive benefits and back-to-work system
The next Government should:
1. Redesign the benefits and back-to-work system to support positive and open engagement with people with mental health problems rather than focussing on unfair assumptions about a lack motivation or willingness to work.
2. Promote a better understanding of mental health, and why people with mental health problems may be out of work, among all relevant frontline staff and contracted providers within the benefits and back-to-work system.
3. Lead and foster a balanced debate about benefits, focusing on the real reasons the vast majority of people need support, such as the difficulties people with mental health problems may face in finding work.
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An effective gateway to support
1. The next Government should redesign the Work Capability Assessment (WCA) so it better understands the barriers to work that people with mental health problems face and what support they would need to overcome them.
2. The decision around what benefit to direct people to should be based on this reformed WCA process and a consideration of whether:
• they will be able to cope with the expectations that will be placed on them
• they will receive appropriate support to help them overcome the barriers they face
• the support and expectations will be conducive to their health improving.
3. Knowledge of an individual’s barriers to work and what support they need to overcome them, gained from a reformed WCA, should be shared with advisors and providers to help them shape personalised and tailored back-to-work support.
Better back-to-work support
The next Government should:
1. Take people with mental health problems on ESA out of the Work Programme and Jobcentre Plus (JCP) and direct them to a new specialist back-to-work scheme.
2. Create a new specialist scheme for people with mental health problems on ESA, designed around the following principles:
• Understanding and trust.
• Individual ambitions and aspirations.
• Specialist and person-centred support.
• Proactive engagement with employers.
• Continued support in employment.
• Integration with health and other local services.
• Focus on health outcomes as well as employment.
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“ I was suffering in silence because managers and colleagues didn’t know what I was going through.”
1: Living and working with a mental health problem
Chapter Overview
• Mental health problems and their symptoms can make work difficult, and work can have a negative impact on people’s mental health.
• With the right support, people with mental health problems can remain in work.
• Understanding the barriers faced by people with mental health problems is key to helping them stay in or move into work.
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• Difficulty concentrating
• Loss of interest in day-to-day activities
• Loss of appetite
• Irritation and agitation
• Self-doubt
• Feelings of worthlessness and hopelessness
• Compulsive activities and behaviour
• Intrusive or repetitive thoughts
• Delusions
• Lack of energy
• Low motivation
• Insomnia
• Difficulties with social interaction
• Fear or panic
• Disturbed or illogical thought patterns
• Paranoia
• Suicidal thoughts or thoughts of self-harm
• Hallucinations.
Although medication can help relieve some of these symptoms, it can also have side effects, such as drowsiness, poor concentration, slowed thinking, sleep disturbance, nausea and shaking.
Symptoms of mental health problems
Mental health problems are complex and there are many different types. They can affect the way you think, feel and behave and can also be considered a disability, just like some physical health problems.5 Often there is a lack of understanding about what people with mental health problems go through and the challenges they face in everyday life. Symptoms like anxiety or low mood are familiar to most of us but other symptoms (some specific to particular conditions) are often forgotten. They include:
Impact of mental health problems at work
Experiencing a mental health problem can cause great difficulty in someone’s day-to-day life and can also have big implications for their working life. Here are some examples of the effects mental health problems can have on working situations.
Despite these barriers, many people with mental health problems are able to work, and research shows that people with mental health problems have a high ‘want-to-work’ rate.6
Working situation Impact of mental health problems
Social interaction Self-doubt, intrusive thoughts, paranoia and low mood can make it difficult to be involved in social situations, whether it be meeting with customers or presenting to colleagues.
Concentration and attention
Difficulty with concentration is a common symptom of mental health problems. Having to finish that report in time, or focus throughout important meetings may become difficult and distressing.
Physical exertion Having not been able to sleep, or losing your appetite could leave you with no energy to complete tasks at work. You could also be distracted or confused, leaving yourself at the risk of injury.
Dealing with pressure
Anxiety and low mood may affect your ability to deal with pressure at work, leading to further distress, particularly when coupled with factors like difficulty in concentrating, or compulsive behaviour.
Ability to communicate
Mental health problems can make it difficult to organise your thoughts and lead to confusion when trying to communicate. Anxiety around social interaction can also hinder your ability to communicate.
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The relationship between work and mental health
The context and conditions in which someone works can clearly have a significant impact on their mental health, and their ability to stay in work if they do have a mental health problem. Effective in-work and back-to-work support must take this into consideration.
It is widely acknowledged and evidenced that employment is generally good for mental health and wellbeing.7 However, inappropriate or poor quality work can have as negative an effect on people’s mental health as not being in work.8
As such, being in work does not necessarily lead to good mental health or recovery from a mental health problem.
Work itself can also have a negative impact on people’s
mental health. People who are employed report that work
is the single most stressful factor in their lives, above debt,
health and relationships.9 We often hear from people who
are struggling to cope with the challenges of long hours,
unrealistic expectations or deadlines, unmanageable
workloads, lack of control over work, the blurring of
traditional work-life boundaries, and job insecurity.
This issue gets insufficient attention from policymakers
and employers, who often fail to recognise just how
much our wellbeing is affected by the workplace
environment and culture.
Employer attitudes and workplace culture
“�One�of�the�key�issues�for�me�is�that�it’s�not�only�difficult�to�find�a�job�but� also�difficult�to�find�a�job�where�the�employer�is�happy�to�take�on�someone�with�a�mental�health�problem.”
Employers play a huge role in determining whether people with mental health problems are able to find and stay in work. Yet we know that many employers have negative views about mental health problems.
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Andy, 52Andy has personal experience of falling out of work due to mental health problems. He used to be a headteacher but after suffering from a deep depression and not gaining the right support, he had to leave his role.
“Up until 2005 I was, on the surface, a successful, competent head teacher. I lost ‘it’ nine years ago and have since struggled to get ‘it’ back. If you have been at the top of your profession, it is a long way down. I used to successfully run a popular and well-respected school. But running a school takes its toll, especially for someone with anxiety.
“On the surface, I was Mr Congeniality - calm, in control, pleasant, efficient, organised. But in my head I was slowly burning out. One day the smouldering flame extinguished – I fell into the pits of a deep depression and had a complete emotional breakdown.
“I want to work, but acknowledge that to do so I may need support from time to time. I need a safety net, not a harness; a flexible system that acknowledges the fluctuating nature of mental health problems, not a rigid structure that restricts ambition and creates obstacles and uncertainty every step of the way.”
We frequently hear from people who have been bullied, demoted or dismissed because of their mental health problems.
A 2011 Populus poll of 2,006 adults in employment revealed that of those who disclosed a mental health problem, 22 per cent were sacked or forced out of their jobs.12 This is clearly a factor that needs to be considered and addressed if more people with mental health problems are to be supported into work, and is discussed further in the next chapter.
Fewer than four in ten
employers would knowingly employ someone with a mental health
problem10
40 per cent of employers view
workers with mental health problems as a
‘significant risk’11
14
“�I�had�many�anxieties�about�facing�people,�a�lack�of�confidence�and�fears�my�depression�and�anxiety would get in the way.”
2: Supporting people experiencing a mental health problem in work
Too often, people with mental health problems fall out of work because they haven’t been adequately supported in their job. However, falling out of work is often the worst possible outcome. It can make people more unwell, and those off work for more than six months have only a 20 per cent chance of returning to work in the next five years.13
Employers that create supportive working environments and make appropriate adjustments for staff will reap the benefits. Some £2.4 billion is spent every year on employees who leave work because of a mental health problem.14
Adjustments for mental health are often about a change of attitude or culture and are usually relatively small and inexpensive.
Poor in-work-support
A 2013 Populus poll15 commissioned by Mind revealed:
• 45 per cent of workers say staff are expected to cope without mentioning stress at work
• 42 per cent of workers believe that in their workplace stress is regarded as a sign of weakness or that you can’t cope
• only a third agreed that time off for stress is treated as seriously as time off for physical illness.
Many workplaces are simply not conducive to staff maintaining good mental health. People frequently tell us they do not feel able to seek support when they need it, and the right sort of support is often not available.
These barriers to seeking support are even more
pronounced in workplaces where employers do not talk about mental health and have not taken positive steps to support and maintain good employee mental health. Unfortunately this picture is still the reality in the majority of organisations.
• 72 per cent of employers have no specific policy to help staff maintain good mental health.16
• Almost half of employees say their organisations do not promote health and wellbeing and only 28 per cent said they knew what wellbeing benefits were on offer and how to access them.17
• A third of UK organisations, which have identified stress as one of their top five causes of absence, are not taking any steps to address it.18
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Chapter Overview
• Poor in-work support is widespread, with mental health a taboo in many workplaces.
• Employers should prioritise mental health and wellbeing among staff.
• Promoting good in-work support should be a key part of any Government employment policy and would help reduce the need for back-to-work support.
Scared to speak outIt’s a huge problem that people with mental health problems often still feel they need to lie about why they are absent from work, as telling their employer the real reason isn’t an option and would result in being judged and possibly dismissed. Outdated and damaging views about the impact a mental health problem can have on somebody’s ability to carry out their role are all too common.
Access to health services
“�Support�from�my�GP�was�excellent,�but�she�was�unable�to�refer�me�on�to�mental�health�services�as�no�one�was�accepted�unless�nearly�dead�or�dying.”
Although employers have a key role to play, it is also incumbent on the health system to ensure people are getting the support they need to stay well and stay in work.
Outside of the workplace, sources of support are hugely overstretched and mental health services are unable to cope with demand for psychological therapies. The Chief Medical Officer (CMO) reports that 75 per cent of people with diagnosable mental illness receive no treatment at all.25
Huge variations in referral rates and waiting times around the country are making people more unwell. One in ten people are waiting over a year between referral and assessment, while four in ten wait more than three months. Once assessed, most people start therapy within three months, yet a third wait longer. While waiting, two thirds feel they have become more mentally unwell.26
This means that people are struggling to access the support they need, which makes it harder for them to stay in or get back into work.
Managers lack confidence on mental health
“�Working�reduced�hours�helped�initially�but�I�felt�unsupported�by�my�manager� and�pressured�into�increasing�my�hours�back�up�before�I�was�really�ready�to.� So�it�defeated�the�purpose.”
Due to a lack of understanding of mental health, managers can be unaware that their staff are struggling or, if issues are suspected, they often lack the confidence to broach the subject. Most managers don’t feel they have enough training or guidance to support staff. Over half of managers said they would like to do more to improve staff wellbeing but they needed more training and guidance. Almost half said they would like to do more but it is not a priority in their organisation.23
Organisations often lack confidence and awareness around developing appropriate policies, support and adjustments to help people with mental health problems stay healthy in work. Only 30 per cent of the UK workforce has access to specialised occupational healthcare and even for those that do, we hear that it is often poor, ineffective or unhelpful for people with mental health problems.24
It’s not surprising that many people feel unable to open up about their mental health in work, which in turn creates a culture of silence.
• 30 per cent of people wouldn’t feel able to tell their boss if they were stressed at work and nearly half say they would feel uncomfortable talking about their mental health.20
• Less than half of people with a mental health problem had told their manager.21
• While stress has forced one in five workers to call in sick, 95 per cent say they have lied to their boss about the real reason for not turning up.22
This self-perpetuating taboo not only leads to significant underreporting of the problem, but also reinforces prejudice. Problems can spiral as people don’t get the timely support they need which could steer them away from developing a more serious problem.
16
94 per cent of UK business leaders
admit that mental health prejudice is an issue in
their organisation.19
17
What good in-work support looks like
“�I�had�regular�contact�with�my�employer�during�absence�from�work�and�received�phone�calls�and�flowers.�I�also�had�an�assessment�from�Occupational�Health�on�my�return�to�work.�Colleagues�ensured�I�had�regular�breaks�away�from�the�PC�when�back�at�work�and�made�sure�I�got�a�suitable�lunch,�even�if�I�didn’t�feel�like�eating.�If�I�had�a�bad�day�I�could�phone�or�email�in�and�say�I�was�working�from�home�and�feel�no�pressure.”
Employers should be taking the mental health and
wellbeing of their staff seriously, and this is something that
Government should proactively support and encourage,
as recommended by the Chief Medical Officer.27 Three in
five people surveyed by Mind said that if their employer
took action to support the mental wellbeing of all staff,
they would feel more loyal, motivated, and committed.28
With the right support, people with mental health problems can, and do, make a hugely valuable contribution to workplaces all over the country. If this support is not available, the talent and experience of hundreds of thousands and people will be missed out on.
We recommend employers take a three-pronged approach (see below) to managing mental health at work.
1. Promote wellbeing for all staff
Effective management is the key to unlocking the potential of employees and preventing stress or poor mental health. Raising awareness of wellbeing and promoting open discussion helps to overcome mental health stigma. Encouraging a good work/life balance allowing flexible hours or home working, ensuring staff have autonomy as well as promoting positive working relationships and social activities are also key.
2. Tackle the causes of work-related mental health problems
Work environment and culture can be triggers for stress and poor mental health. Solutions include training managers to recognise mental health problems, support employees and help them to manage their workloads, improving the physical environment, providing on-the-job coaching and publicising available support, such as Employee Assistance Programmes (EAPs). Ensuring regular supervisions or one-to-one meetings are standard practice is crucial, to build trust and give employees an opportunity to raise issues at an early stage with managers.
3. Support staff experiencing mental health problems
Everyone’s experience of a mental health problem is different and so is the support they need. Policies on reasonable adjustments and phased returns to work are crucial but the first step is to establish honest, open communication with the employee.
Adjustments could include:
• Flexible hours or change to start/finish time
• Changes to role (temporary or permanent)
• Increased support from managers in prioritising and managing workload.
18
Some top organisations do talk about mental health now and prioritise it. Sadly, this enlightened approach is far from universal and we need a stronger business voice on mental health. A number of initiatives are working to encourage more businesses to take the mental wellbeing of their staff seriously and do more to support staff who are experiencing mental health problems.
Time to Change (TTC)
England’s biggest programme to end the stigma and discrimination faced by people with mental health problems works with organisations, engaging them on this issue and generating tools and resources for them. Over 260 organisations have made a public commitment to tackle mental health stigma by signing the pledge, including BAE Systems, British Gas, BT, Channel 4, E-ON, Lloyds TSB, and PepsiCo.
City Mental Health Alliance (CMHA)
Launched in October 2013, the CMHA is a coalition of City-based employers committed to breaking down stigma and creating a culture where mental wellbeing is nurtured as part
of good business practice. Championed by senior leaders, the Alliance is business-led and expert-guided and aims to create a culture of good mental health for City workers, increase understanding and share best practice. Founding organisations include Bank of America, Merrill Lynch, Deloitte, Goldman Sachs and KPMG.
Business in the Community’s (BITC) Workwell Mental Health Champions Group
This group provides clear leadership from business, for business, on mental wellbeing. Its goal is to help mental health become a strategic boardroom issue, and encourage employers to take preventative and supportive action on employee mental health just as they do on physical health. Founding members include BT, Bupa, RBS, and Mars.
Role of government
Government also has a key role to play in this area. Through schemes like Disability Confident and Two Ticks, they can encourage employers to do more to understand disability and support people in the workplace. However, these schemes need to be built upon and expanded if they are to have a widespread and significant impact.
Government can also directly support employers through schemes such as Access to Work, which can provide the advice and resources that are needed to help someone with mental health problems stay in work. However, this scheme has been hugely underused for mental health, with only four per cent of the budget in 2013-14 being spent on this group.29
19
Anne-Marie, 28Anne-Marie spent over 11 years working in a customer-facing role - assisting customers, stocking shelves, and working on tills. She enjoyed being able to give customer satisfaction, especially shopping with elderly and disabled people. It helped her feel better about herself. However, due to a mental health problem she cannot currently work.
“I was suffering in silence because managers and colleagues didn’t know what I was going through. At work they just didn’t have the knowledge to deal with a mental health illness. So I didn’t bring it up because I was afraid of being judged or being looked down on.
“If I had a broken leg, they could have physically seen it, and workplace adjustments would have been made. Every job by law has a first aider so if someone hurts or burns themselves or falls down the stairs, there is someone to assist them or professional help is available. But what happens when my mind goes into crisis? Where do I go in the workplace? I was taking my problems home and I was causing further damage to myself. But in the workplace where are there avenues for us to turn to or people to speak to?”
While off from work due to illness, Anne-Marie felt increasingly isolated, neglected and rejected which led to her trying to take her own life. After leaving hospital work wasn’t on her mind.
“I remember returning to work and I felt so lost. I wasn’t sure what I was supposed to do and I didn’t really know where I was. I had a meeting about why I was off and how they could support me. I wasn’t in a place to tell them my needs or say ‘This is what I require’. So I just went back to work and was very unhappy, which led to me being off again.”
Our vision for in-work support
If government and employers get in-work support right, it will lead to improved wellbeing for all employees and fewer people will fall out of work. This in turn will lead to fewer people needing support from benefits, back-to-work schemes, and healthcare services. Better in-work support will also make workplaces more receptive and appropriate for people with mental health problems trying to move into work.
Recommendations
1. Employers need to do more to promote wellbeing in the workplace and support people with mental health problems to stay in work, following the lead of those who have signed up to Time to Change or joined such campaigns as Business in the Community (BITC) or City Alliance.
2. The next Government must do more to promote better in-work support to employers, which includes:• expanding on current schemes such as Disability Confident• promoting schemes that recognise the work of good employers • continuing to support the Time to Change campaign to tackle stigma and discrimination• reforming the Government’s Two Ticks scheme• ensuring SMEs are supported to provide comprehensive in-work support.
3. The next Government should improve its own in-work support offer to people with mental health problems who are at risk of falling out of work.
• Access to Work should be better promoted and made more accessible for people with mental health problems and should aim to direct at least 10 per cent of the budget towards this group.
• The new Fit for Work service should retain its person-centred approach to supporting people during sickness absence but must also effectively engage employers in the process.
20
“�I�need�a�safety�net,�not�a�harness;�a�flexible�system�that acknowledges the fluctuating�nature�of�mental�health�problems.”
21
3: The benefits system and how it affects people with mental health problems
Chapter Overview
• People with mental health problems want to be in employment, and it is the barriers caused by their condition, rather than a lack of motivation, that makes work difficult.
• The benefits and back-to-work system often assumes that people don’t want to engage with support and need to be pushed into it.
• These assumptions fundamentally undermine the design and delivery of support for people with mental health problems, making it ineffective and often inappropriate.
Benefits provide a vital lifeline for people who are unable to work at this time because of their mental health problems. People frequently tell us that they feel the benefits system is working against them rather than supporting them. We’ve found that this is because of a lack of understanding about mental health problems, and assumptions that are made about why people have ended up on benefits.
Why people aren’t in work – assumptions and reality
“�Many�years�ago�before�all�this�happened,�when�I�had�my�breakdown,� I�had�a�really�good�job�and�I�loved�it.�One�day,�I�do�want�to�go�back�into�work�and�be�more�independent.”
People with mental health problems have a high ‘want-to-work’ rate.30 This is reflected in two recent surveys of people with mental health problems currently out of work, which showed that the majority wanted to be in employment. It is usually the impact of their mental health problem and the environment they are expected to work in that create the biggest barriers to employment.31 Yet the benefits system does little to recognise this, and instead operates on two flawed assumptions, which are:
• people are likely to overstate the impact of their condition – either intentionally in order to maximise their support from the benefits system, or simply as
a result of inaccurate beliefs about how much their condition actually impairs their ability to work
• the main barriers to overcome are people’s lack of motivation and/or willingness to engage with back-to-work support and to, ultimately, return to work.
Since mental health problems fluctuate and are largely ‘invisible’ to an outside observer, it can be easy to assume that someone is ok when they are actually struggling. Symptoms such as low mood, problems with social interaction and issues with motivation could be confused with a lack of ambition to work or willingness to engage.
22
The public debate about benefits
“�I�don’t�want�to�be�on�benefits�because�at�the�moment�I’m�made�to�feel�like�a�scrounger.�I’ve�even�had�everyday�people�question�it.”
These assumptions reinforce, and are reinforced by, the public debate about benefits. Through our membership of the Who Benefits? campaign, we have expressed serious concern about the debate around benefits in politics and
the media, and the impact this has on people supported by benefits.34 Research by the campaign shows that rhetoric around benefits has a real impact on the people who need support from benefits. Of people surveyed:
38 per cent said their confidence and self-esteem was affected because they
worry that the general public think negatively of them being
on benefits.
31 per cent said their mental health
is affected.
15 per cent said they experienced verbal abuse because of being on benefits.35
The impact of misplaced assumptions
“�There�was�no�apparent�understanding�or�sympathy�with�my�background.� Some�jobcentre�staff�were�harsh,�threatening�and�unsympathetic.�It�made�me�tearful.”
The flawed assumptions described above have a significant impact on people with mental health problems at key points in the benefits and back-to-work system.
• The feeling of being ‘processed’ by the benefits system rather than listened to and understood.
• The way in which the WCA assesses people, looking to the individual to ‘prove’ their condition affects their ability to work, and making inferences about their ability to perform activities rather than simply discussing this directly.32
• The type of employment support offered to the majority of people through Jobcentre Plus (JCP) and
the Work Programme, focusing on issues such as punctuality and motivation rather than addressing the specific barriers people face as a result of their mental health problem.33
• The heavy focus on conditionality and sanctions in the benefits system, which assumes people are unwilling to engage with support and need the threat of benefit cuts to motivate them.
These misplaced assumptions are leading to ineffective support, as shown by the fact that the vast majority of people with mental health problems are not being supported to move towards work. In essence, it is the wrong diagnosis leading to the wrong treatment.
23
Our vision for a fair and responsive benefits and back-to-work system
If the benefits and back-to-work system is to become effective at supporting people with mental health problems, it needs to be built around an understanding of why people with mental health problems need support. The misplaced assumptions described in this chapter need to be recognised, challenged, and overturned if future reforms of this system are going to have real impact.
Recommendations
The next Government should:
1. Redesign the benefits and back-to-work system to support positive and open engagement with people with mental health problems rather than focussing on unfair assumptions about lack of motivation or willingness to work.
2. Promote a better understanding of mental health, and why people with mental health problems may be out of work, among all relevant frontline staff and contracted providers within the benefits and back-to-work system.
3. Lead and foster a balanced debate about benefits, focusing on the real reasons the vast majority of people need support, such as the difficulties people with mental health problems may have with finding work.
The Disability Benefits Consortium (DBC) Big Benefits survey found similar results.
• 81 per cent of respondents with mental health problems felt ashamed of being on benefits because of societal attitudes.
• 84 per cent felt that society looks down on them.36
All of this only makes it harder for people to overcome the barriers they face which lead to them needing support from benefits.
24
“ It’s a black and white�mentality,�“fit�for�work/unfit�for�work”,�phrasing�designed to catch people�out.�Most�people�are�capable�of some work. But there are so many different shades.”
4: The Work Capability Assessment the gateway to support?
25
Chapter Overview
• The WCA is not only stressful for people with mental health problems, but also fails to understand and recognise the barriers to work people face.
• The WCA should play a crucial role as the gateway to back-to-work support, but at present it only really functions as a benefits eligibility test.
• The WCA needs to positively engage with people with mental health problems, and better understand the barriers to work they face, to help improve the support they receive.
The WCA is used to assess eligibility for ESA and plays a critical role in deciding what sort of financial support people can access, what back-to-work support will be available, and what people will be expected to do in order to continue to receive the benefit.
The WCA has been a problematic area of policy, with over 50 recommendations from five Independent Reviews, and substantial criticism from government committees and disability organisations. However, these
criticisms have tended to focus on the technical design and operation of the WCA. This has led to ongoing reform that has, to some extent, improved the process for people with mental health problems. However we believe that if the WCA is to effectively understand the barriers people with mental health problems face and support them to move closer to work, it needs more fundamental reform with a greater focus on the wider role it plays in the back-to-work process.
90 per cent of respondents
with mental health problems found the assessment process
stressful
over 85 per cent felt that it made their
health worse.39
Mental Health and the WCA
There is widespread recognition that the WCA is particularly problematic for people with mental health problems. The fourth Independent Review of the WCA stated that there “remains considerable concern that the current system is not operating as well as it might for this group”,37 and the Work and Pensions Select Committee have called for the WCA to be made more responsive to those with mental health problems.38
People with mental health problems face particular difficulties engaging with the WCA process. This is because they may find it hard to advocate for themselves and communicate the impact their condition has on their ability to work. In addition, the process can have a particularly negative impact on people with mental health problems because of the anxiety it often causes. A recent Disability Benefits Consortium (DBC) survey found:
These difficulties were recognised in a recent Judicial Review about the WCA, which concluded that the WCA process is disadvantaging people with mental health problems by not adequately responding to these difficulties.40
Despite this criticism and the ensuing reforms, people with mental health problems continue to feel that the process does not work for them or understand their condition. A recent survey found that:
• 70 per cent of respondents felt their condition had not been properly understood
• 60 per cent of respondents felt they had not been asked in adequate detail about how their condition affects their ability to work41
Role of the WCA
The third Independent Review of the WCA stated, “The end-to-end WCA process intends to evaluate objectively a person’s capability for work so that appropriate support can be provided to help them back to work.”42 However, the current isolated nature of the WCA means it functions as an eligibility test for ESA but not an assessment of what support is needed.
Through the WCA, people are placed in one of three groups based on the number of points they are allocated in the assessment:
• ‘Fit for Work’ – for people who are considered ready to return to work now
• Work-Related Activity Group (WRAG) – for people who are not considered ready to work now, but are seen as able to start preparing for a return to work
• Support Group – for people who are considered to be both unable to work now, and not ready to start preparing for work
There is a problem with this approach. There’s no evidence to show the points people are scored means they will be assigned to a group with appropriate support and expectations.
The Welfare reform Act 2012 increased the range of activities that could be made mandatory for people in the WRAG and the severity of the sanctions for failing to complete these activities.43 However, this significant change to what being in the WRAG entails did not lead to a review of the points threshold that decides who should be placed in this group.
The findings of the Evidence Based Review of the WCA further highlight how the assessment and categorisation sit separately.44 Expert panels looking at ESA applications were instructed by the DWP to consider people ‘fit for work’ if they may be able to work with the assistance of adjustments such as flexible or altered hours, periods of disability leave, and having access to a support worker.
In 83 per cent of cases where the expert panel found someone ‘fit for work’, they indicated they would need, on average, at least two of these adjustments. However, in reality it is often very difficult for people to get access to this support. For most people facing these kind of barriers to work, the WRAG would be a much more appropriate group.
The WCA needs to have a much greater focus on the barriers people face being in work and what support they would need to overcome them. The process for allocating applicants to different groups should be redesigned with a focus on these key considerations:
• Whether they will be able to cope with the expectations that will be placed on them.
• Whether they will receive appropriate support to help them overcome their barriers.
• Whether the support and expectations will be conducive to their health improving.
This approach would ensure that applicants are being placed in groups that are appropriate for them. It would also refocus the allocation process on ensuring that people get the support that they need to overcome the particular barriers they face.
A more accurate and comprehensive WCA would be required, one which fully understands the barriers someone faces, the support they could benefit from and how they would cope with the requirements of the group they are placed into.
Once the WCA has allocated someone to a particular group, it should provide key information for staff at subsequent stages in the back-to-work process. However, it is currently rare for the information collected in the WCA to be passed onto the providers tasked with supporting people back to work. This immediately restricts the ability of the advisor to direct people to appropriate support activities that are productive in helping them to move closer to work.45
26
27
Lee, 38Lee has had numerous mental health problems for a number of years including depression, anxiety and personality disorder. For a number of years he received incapacity benefit but with the changes to the benefits system he was automatically moved over to ESA and placed in the Work Related Activity Group, before being asked to have a WCA.
“Personally it was a disaster. I received the form to fill in first. I had two weeks to gather evidence but that wasn’t enough time. I made a request for a private room, but when I got there I ended up being locked in a room with a security guard. My appointment should have been at eleven o’clock and I didn’t actually get to see anybody until quarter to one. There were no windows I had anxiety and I was having panic attacks.”
After being assessed, which Lee found very stressful, he was placed in the WRAG.
“I had to attend a weekly self-help management course at my local Jobcentre. The course lasted for six weeks and I had to attend or face sanctioning. But it was focussing more on people in pain, people who had bad backs and first aid. It was based on physical health, and I did say a number of times at these meeting that this doesn’t apply to me. I’m not in pain as such, I have a mental health problem.
“If the group was actually set up for people with mental health problems, rather than just physical disability, to let people talk about their worries and fears about the workplace and that sort of thing, I think that would have helped me tremendously. Now I don’t know what’s happening or whether I’m going to receive another ATOS assessment, the thought of which is actually scaring the hell out of me.”
Our vision for an effective gateway to support
If the benefits and back-to-work system is to help more people with mental health problems into work, it has to be able to engage with them positively, make sure they feel understood and supported, and help them to overcome the barriers they face. Since the WCA plays such a key role in this process, and is the first key point of contact for many people, it is particularly important that people believe that this process is fair and accurate, and that it is there to understand the impact of their condition and direct them to the support that they need.
Recommendations
1. The next Government should redesign the Work Capability Assessment (WCA) so it better understands the barriers to work that people with mental health problems face and what support they would need to overcome them.
2. The decision around what benefit to direct people to should be based on this reformed WCA process and a consideration whether:
• they will be able to cope with the expectations that will be placed on them
• they will receive appropriate support to help them overcome the barriers they face
• the support and expectations will be conducive to their health improving.
3. Knowledge of an individual’s barriers to work and what support they need to overcome them, gained from a reformed WCA, should be shared with advisors and providers to help them shape personalised and tailored back-to-work support.
28
People�should�be�nurtured through a situation when they’re not feeling well instead of having to have a battle
29
5: Why back-to-work support isn’t working for people with mental health problems
Government back-to-work schemes are failing to support the vast majority of people with mental health problems to move into employment. The mainstream support offered through JCP and the Work Programme has proven to be insufficient and, often, inappropriate for this group.With over 45 per cent of those on ESA having mental health
problems as their primary condition, and many more also experiencing mental health problems as a secondary condition, bold action is needed to improve the outcomes for this group.46 This chapter explains why these schemes are failing this group and why simply amending existing schemes will not meet the scale of the challenge.
Chapter Overview
• Mainstream government back-to-work support schemes are failing people with mental health problems, offering generic and inappropriate support due to a lack of understanding about mental health and misplaced assumptions about why people need support.
• Specialist schemes have proved to be much more effective for this group, but are only offered to a small minority of people with mental health problems.
• Bold action is required. Whilst the Government has acknowledged the issue, the scale of the challenge has not been fully recognised. People on ESA should be taken out of these mainstream support schemes and directed to a new specialist scheme.
Back-to-work schemes for people on ESA
People placed in the Work Related Activity Group (WRAG) of ESA are required to engage with support provided by JCP or the Work Programme, depending on how far away from being able to work they are considered to be. JCP can also refer people onto Work Choice but, as discussed below, this only happens in a small number of cases.
• Of over almost 150,000 people with mental health problems on ESA who have been placed on the Work Programme, only 5 per cent have been helped into work, compared to the programme’s success rate of 24 per cent for people without a health condition.47
JCP does not record job outcomes for people on ESA, which means it is impossible for the Government or others to properly evaluate the support provided. However, evidence suggests that the support provided is similar in nature to that on offer through the Work Programme, and is leading to similarly poor results.48
Both the Work Programme and JCP are providing generic support, focusing on basic job-seeking skills and behaviours.49 This is particularly disappointing for the Work Programme, which was expected to direct people towards specialist support, “providing each individual with what they need”.50
Work Choice was created for people seen as having complex employment support needs related to their health or disability. It is a voluntary scheme that focuses on “helping individuals to achieve their full potential and moving towards being more independent” but it also “ensures employers get the support they need to employ more disabled people”.51
People on both ESA and JSA can be referred to Work Choice by Disability Employment Advisors (DEAs) within JCP. Since its inception in 2010, 78,740 people have started Work Choice with 29,520 finding employment (29%).52 For people with mental health problems the outcomes are extremely positive, far exceeding mainstream schemes.
Work Choice success rate for those with mental health problems53
However, referrals to Work Choice are aimed at those
participants who are expected to be capable of working
over 16 hours per week within six months. As a result,
many more people are referred to Work Choice from
JSA than from ESA.54
This means that the more personalised and flexible
model is considered appropriate for those deemed to
be relatively close to work, while a much more generic
approach, with tougher requirements, is used for people
with much more significant barriers.
The Government’s Disability and Health Employment Strategy (DHES) indicates that Work Choice and other similar programmes will continue to only be provided for a minority, “The majority of disabled people with health conditions who need employment support will receive our mainstream offer”.55 This is a far from obvious conclusion, when all the evidence is that this ‘mainstream offer’ is returning very poor results for people on ESA, and is proving particularly ineffective for people with mental health problems, who make up such a large proportion of this group.
Condition Started Job outcomes % success rate
Severe mental health 650 240 36.9
Mild-moderate mental health 11,020 4,490 40.7
30
Lack of understanding of mental health and related barriers
“ The advisors had little knowledge about mental health and when I asked to see the�specialist�they�had,�it�became�apparent�she�knew�little�more�than�the�others.”
Before people on ESA are passed onto JCP or the Work Programme, they will have been through a WCA categorisation process that often fails to properly assess what barriers they are facing and what support they need to overcome these barriers. As explained in Chapter 4, this is a missed opportunity to positively engage with people and gather vital information to shape the employment support services they receive.
Without this information, JCP and Work Programme providers are starting from a difficult position. With a lack of expertise in mental health, and often working from misplaced assumptions, back-to-work schemes
tend to end up providing generic support to people with mental health problems, failing to properly address the barriers they are facing.
We do not believe that Work Programme providers or JCP are doing enough to ensure that staff have sufficient expertise and understanding in mental health to support the large proportion of their clients who are experiencing mental health problems. Jobcentres do employ Disability Employment Advisors (DEA) to provide specialist support for people with disabilities. However, the numbers of DEAs has decreased by 30 per cent between May 2011 and May 2014.56
Why mainstream schemes are failing
The mainstream government back-to-work support being provided to most people on ESA because of their mental health problems isn’t working. This is the culmination of a wider system that is failing to understand people with mental health problems who are struggling to work, and provide the support they need.
Support that is ineffective and often inappropriate
“�They�simply�did�what�I�could�already�do�on�my�own,�put�together�a�CV�and�search�for�jobs.�There�was�not�enough�support�geared�to�my�specific�difficulties.�Every task was the same for everyone. Not everyone’s needs are the same.”
This lack of understanding and expertise around mental health leads to back-to-work schemes advisers not having the capacity to identify the sort of support people might benefit from.
Within JCP there seems to be a lack of relevant services to refer people onto, even if their barriers had been correctly identified. Instead, people are referred onto a limited number of classes and workshops that do little to help most people with mental health problems move closer to work.
It was expected that the Work Programme would be better equipped to refer people onto specialist services, through the network of sub-providers that the prime providers were expected to establish. However, the DWP’s own evaluation of the Work Programme suggests that this is not leading to appropriate specialist support being provided.57
Instead, people with more complex needs are often left ‘parked’ by providers.58 This is, in part, due to insufficient financial incentives to support this group. We want to see sufficient resources directed towards those who need the most intensive support. However, our experience suggests that there are much more fundamental issues to be addressed if schemes like the Work Programme are to be effective for people with mental health problems.
Not only is there a lack of specialist support, but the activities people are asked to do are often inappropriate, their condition is not properly taken into account, and they don’t feel involved in shaping these activities.
If people are not involved in deciding what their support will look like, and do not feel the support they are being directed to is appropriate for them, they are much less likely to be able to engage.
31
Only 23 per cent of people felt their ‘action plan’ of support was appropriate for them
Only 21 per cent felt involved in making the
plan and agreeing to the activities
Only around 30 per cent felt their adviser had adapted activities
to take account of their condition and the impact it had on their ability to
engage.59
In recent research of people in the WRAG:
Excessive focus on conditionality and sanctions
“�It�didn’t�help�at�all.�If�anything�it�caused�even�more�stress,�worry,�anxiety.�It�was�really�hard�for�me�to�push�myself�to�go�to�these�[appointments]�every�week,�knowing�that�if�I�didn’t�go�or�if�I�was�late�then�my�benefit�would�be�stopped.”
There has been an increasing use of conditionality and sanctions for people on ESA. Yet there is little evidence that it is an effective way of structuring support for this group. Because of the particular characteristics of mental health, this group are at a significantly greater
risk of sanctions being inappropriately applied. It’s hard to see an alternative explanation for the increasing proportion of ESA sanctions falling on this group. This is unacceptable and needs to be urgently reviewed.
As a result, thousands of people with mental health problems are facing very difficult financial circumstances, which they tell us exacerbates their condition.60 Research shows that the vast majority of people (86 per cent) in the WRAG feel anxious about the risk of losing their benefits if they are not able to do the activities asked of them.61 This means that people are less able to engage positively with the support they are being directed towards.
ESA Sanction Rates 2012-2013Calculated from DWP statistics on rates of sanctions https://www.gov.uk/government/collections/jobseekers-allowance-sanctions and freedom of information request responses on the proportion of sanctions falling on people with health conditions https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/295384/foi-79-2014.pdf https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/343310/foi-2014-2282.pdf.
All ESA Sanctions
Mental & Behavioural Disorders
All other condition groups
5000
4500
Jan-
12
Feb
-12
Mar
-12
Apr
-12
May
-12
Jun-
12
Jul-12
Aug
-12
Sep
-12
Oct
-12
Nov
-12
Dec
-12
Jan-
13
Feb
-13
Mar
-13
Apr
-13
May
-13
Jun-
13
Jul-13
Aug
-13
Sep
-13
Oct
-13
Nov
-13
Dec
-13
4000
3500
3000
2500
2000
1500
1000
500
0
32
Lack of local integration and understanding of people’s wider circumstances
A DWP evaluation of the Work Programme suggests the support being offered to people in the WRAG is not matching the complexity of the barriers people face.62 This reflects the reality of life for many people we talk to in this situation. They are facing multiple issues alongside their health and employment situation, such as debt or housing problems, but do not receive support for these. Work Programme providers and JCP seem to lack the specialist expertise and support services to address these issues, or may simply not see it to be part of their remit. These issues will often be rooted in the individual’s location, requiring local knowledge and contacts to resolve.
As a result, large national providers covering a whole
region as part of their Work Programme contract, will often
struggle to fully understand and address these issues.
This lack of proper local integration also makes it difficult
for providers to ensure that they are linking in with the
person’s health support, understanding the local economy,
and proactively engaging with local employers to find
relevant and suitable job opportunities. Connections with
local health support are particularly important to ensure
that services are working together to promote someone’s
recovery from their mental health problem.
People ending up more unwell and further from work
Because of ineffective and inappropriate support, the threat of sanctions and the failure to address wider support needs, back-to-work schemes are actually pushing people on ESA (not just those with mental health problems) further from employment, worsening their mental health and decreasing their confidence.63 Research carried out for this report shows that this effect is particularly acute for people with mental health problems.
Of over 400 people with mental health problems asked about the impact of being on the Work Programme or with JCP:
33
82 per cent said it had made their
confidence worse or much worse.
“�My�experience�with�the�Work�Programme�has�made�me�extremely�anxious�and�exacerbated�my�mental�health�problems.�Rather�than�helping�me�back�to�work,�it�has made me more ill.”
83 per cent said it had made their mental health worse or much
worse.
76 per cent said it had led to them feeling less or much less able
to work.
83 per cent said it had made their
self-esteem worse or much worse.64
34
Richard, 45Richard has suffered mental health problems since he was a teenager and has struggled to work because of this. He went through the WCA and was placed in the WRAG and put on the Work Programme in Derby, which he had to travel by public transport to, which in itself he found very difficult. He eventually managed to get a job of his own volition but unfortunately, due to ill health, fell out of this job and has now been placed in the Support Group.
“I went into the Work Programme with an open mind and hoped they would be able to help, but was appalled by the service I received. They didn’t know anything about me or my mental health condition and, rather than find this out, they just did a tick box assessment, asking questions such as “are you prepared to commute?”
The advisors had little knowledge about mental health and when I asked to see the specialist they had, it became apparent she knew little more than the others. Eventually I started seeing the same person more than once, but at first someone different every time, which was difficult. Basically there was very little understanding about my condition and therefore no personalised support, just all generic support.
Just going to the office was stressful, as it was a very busy and loud environment (even keeping the radio on during interviews). The whole experience was very alienating.
During my time on the Work Programme I was hospitalised due to an overdose but because I was so petrified they wouldn’t believe me or that the information would get lost and I would get sanctioned, I turned up to my appointment a couple of days later anyway.”
The scale of the challenge
We do not believe the scale of the challenge has been fully recognised, or appropriate and commensurate reforms considered.
Some of the problems with current support schemes have been recognised by the Government who are now, through the DWP and Department of Health, undertaking pilots of new models of back-to-work support for people with mental health problems. This is a positive step forward, and we would welcome the introduction of some of the innovations being considered. However, we are concerned that these
pilots, based on recommendations in the DWP’s Psychological Wellbeing and Work report,are largely focused on testing relatively minor and isolated changes to the system.65
There seems to be a sense that it will be possible to simply ‘patch-on’ improvements to the current system that will address the failure of these schemes, without looking at the fundamentals. Although we look forward to the evaluations of these pilots, we believe their focus will be too narrow to deliver sufficient reform to address the scale of the challenge we are describing.
35
Our vision for back-to-work support
It’s clear that mainstream back-to-work schemes are not working for people with mental health problems. The evidence shows that they are not suitable for people with mental health problems, not only leading to poor job outcomes but also making their mental health worse. Because of the fundamental flaws in these schemes, bold action is required. Amending current schemes will not be sufficient - instead we need a new specialist scheme, built around the principles described in the next chapter.
Recommendations
1. The next Government should take people with mental health problems on ESA out of the Work Programme and JCP and direct them to a new specialist back-to-work scheme.
2. This new scheme should be designed around the principles set out in the following chapter.
36
“�The�one�to�one�support�I�received�was�incredibly�helpful,�which�gave�me�confidence�…�I�always�moved�at�my�own�pace.”
6: Our vision for back-to-work support for people with mental health problems
We believe tweaks to the current system are insufficient. In this chapter we argue for a bold new alternative, and set out the key principles that a redesigned scheme needs to be based on. These principles are derived from what we have heard from people with mental health problems and the evidence we have seen about what sort of support works for this group.
Creating a new scheme for people on ESA would have some key advantages:
• It would be built around more accurate assumptions about the motivations and support of people with mental health problems.
• The structure of the scheme would ensure that specialist local support, relevant to the person’s condition and circumstances, would be available to them.
• It would represent a new start and would help to regain the trust of people with mental health problems who have largely lost faith in the system.
37
Chapter Overview
• A new model of support for those with mental health problems should focus on the individual, understanding their barriers to work and how to overcome these.
• It should be delivered on a local basis and integrated with local services, working with employers not only to provide suitable jobs, but also ongoing support.
• The success of back-to-work support should not just be judged on whether it finds someone a job or not, but also on the wellbeing of that person.
• The Individual Placement and Support model (IPS) incorporates all of these principles and has had significant success at supporting people with mental health problems into work.
38
The principles of a new back-to-work scheme
Principle 1: Support should be based on understanding and trust
“�Genuine�emotional�support�from�an�advisor you can trust who has real knowledge about your conditions and actually�cares�about�the�people�they�work for and their wellbeing.”
Support schemes for this group need to understand what it is like for people experiencing a mental health problem. This means the people providing these schemes need to have expertise and experience of working with people with mental health problems. They also need to work with their clients to understand the variety of issues they may be facing.
Many people with mental health problems struggle with social interaction and find it hard to open up to an advisor. Being able to communicate effectively with people with mental health problems, and help them to describe the barriers they face, is vital to establishing what sort of support they need. Consistency of support, i.e. having one key point of contact, is also essential for people to be able to establish a relationship of trust with their advisor.
This relationship of trust needs to work both ways – participants in the scheme need to feel that their advisor understands them and is there to help them. Advisors need to start from the assumption that participants are being honest about the barriers they are facing, want to engage with support and want to move closer to work if the right support is offered in the right way.
While it’s widely accepted people should take responsibility for the benefits they receive, it is counter-productive for sanctions to be the foundation of the relationship between someone with mental health problems and their advisor. Instead, the use of conditionality for this group should be a last resort and only discussed when it seems someone is refusing to engage.
Principle 2: Support should focus on individual ambitions and aspirations
“I want to be treated like an individual not�like�I’m�being�pushed�through�a�sausage machine.”
Support should focus on what sort of work people would like to do and what their skills are suited to. If job outcomes are to be sustainable, people need to feel that the job is right for them and provides them with the opportunities to develop and progress. This group of people are out of work because of their health, not necessarily a lack of skills or experience – indeed, many people with mental health problems will have previously been in highly skilled and well paid work. Services need to be equipped to support people with a variety of previous experience and should not simply be looking to push people into any vacancies that arise.
Principle 3: Support should be specialised and person-centred
In a Mind survey of people who had experience of back-to-work support, a “person-centred approach”, i.e. focusing on their specific barriers and needs, was the most commonly mentioned aspect of good or desired back-to-work support.66 There needs to be a dedicated, knowledgeable team who understand disability and illness.
Once people’s barriers, needs and ambitions have been identified, an action plan of appropriate and sufficiently specialist support should be drawn up. This should be co-produced with the individual so that they feel in control of the support they are going to be engaging with, and confident that it is appropriate and manageable.
This approach would bring employment support more in line with services like social care, which starts from the position that someone has been found to face additional barriers, and works with them to explore how these can be overcome. Similarly, it is increasingly the case in healthcare that the patient ‘owns’ their care pathway or, in other words, the system places the person at the centre, being reactive to their needs. In contrast, for people placed in the WRAG, the DWP very much ‘own’ the pathway, and people are expected to comply with, rather than shape, this pathway.
In line with this idea that support should revolve around the person, there should be a wide range of specialist support available for people to choose from. This support should be offered by a variety of providers with different expertise and experience. This would also help to create a more diverse market of locally available support, with providers flourishing or failing depending on how effective and appropriate people and advisors find their support to be.
Principle 4: Support should proactively engage with employers
“�They�need�to�find�employers�who�will�actually�take�on�people�with�mental�health issues.”
In our survey, the role of employers and in-work support was also seen as key by people with mental health problems. Respondents called for closer links with employers to find and create suitable job opportunities, and to address stigma and lack of understanding.
Since getting the right sort of job, with the right sort of in-work support, is vital for people with mental health problems, advisors have a key role to play in working with local employers to find suitable roles, ensure support will be available, and promote the people they are supporting. Only advisors with the appropriate skills, local knowledge and connections will be able to perform this brokerage role effectively.
This should also have a longer term impact on the accessibility of the local jobs market for people with mental health problems, reducing stigma and discrimination and making workplaces more open, suitable and supportive.
Principle 5: Support should continue into employment
“�You�should�have�someone�to�keep�in�contact,�raise�any�concerns�with�my�employer�if�needed,�monitor�my�work�load,�and�know�me�well�enough�to�know if I was struggling.”
As well as supporting someone to move into a job, back-to-work schemes should help someone to stay in that role. This could involve simply checking in with someone on a regular basis to see how they are doing, but could also involve ongoing brokerage with the employer to ensure that the person is receiving the support they need. This support should last for as long as it is needed to ensure that the person is able to maintain employment, even if their mental health worsens.
Principle 6: Support should be integrated with health and other local servicesSince people’s health, and the impact it has on them, is such a key barrier to engaging with support and returning to work, employment support should be integrated with health support. Employment and health services should be aware of the support and advice people are receiving from each and it should be ensured that this advice and support is complementary.
Returning to work can be a key part of someone’s recovery from a mental health problem, but their recovery should be seen as the primary objective. Therefore, employment support providers need to understand the fluctuations and changes in the health of the people they are supporting, and ensure that the support offered is having a positive impact on their health.
Principle 7: Support should be focused on health outcomes as well as employmentThe impact that employment support, and a potential return to work, has on someone’s health should also be part of the measured outcomes. Programmes could use current information such as the Health and Social Care Information Centre Mental Health Bulletin or the Public Health Outcomes Framework, or look to models such as the Warwick Edinburgh Mental Wellbeing Scale.67
This would also help account for costs saved elsewhere to the local economy (for example, secondary mental health services or Improving Access to Psychological Therapies (IAPT)) and allow for easier integration and better commissioning. If Clinical Commissioning Groups are expected to reach certain employment outcomes, and employment services to reach certain health and wellbeing outcomes, the commissioning and delivery of these services would reflect this.
39
The IPS model
The best model currently operating that fulfils the principles outline above is the Individual Placement and Support (IPS) approach. IPS has been shown to be twice as likely to enable people with severe mental health problems to enter work as any other employment support scheme.68 The recent Psychological Wellbeing and Work report also estimated a benefit-cost ratio of 1:41, with the Government saving £1.41 for each £1 spent on the IPS model.69
Although it has not been used as much for people with mild to moderate conditions, the model addresses many of the concerns we have about the support currently on offer to this group. Furthermore, the evidence of the IPS model’s success with people with more severe conditions and more complex barriers is surely more
convincing as a default approach for all people with mental health problems than the minimal success rate of mainstream government schemes.
IPS looks to secure paid employment that matches the person’s interest and aspiration by co-producing a plan of action, rather than requiring them to undertake certain activities. Support continues once the person gets a job and, as these schemes are often based in secondary mental health care service, they are integrated with the person’s health support. At the heart of the IPS approach is the need to build a strong, long-term relationship of trust between the advisor and the person being supported, understanding and addressing the barriers they face.
40
Principles of IPS
1. Every person with mental illness who wants to work is eligible for IPS support.
2. Employment services are integrated with mental health treatment services.
3. Competitive employment is the goal.
4. Personalised benefits counselling is provided.
5. The job search starts soon after a person expresses interest in working.
6. Employment specialists systematically develop relationships with employers based upon their client’s work preferences.
7. Job supports are continuous.
8. Client preferences are honoured.70
In 2009, four separate Government reports all recommended that the IPS approach should be used for people within mental health services who want to gain employment,71 but we are yet to see a large-scale roll-out of the model despite its success.
Interest has generally led to suggestions of taking individual elements of the model and ‘patching’ them on to existing schemes. These suggestions miss the point – it is through embracing all the key principles outlined above that IPS is so successful. As such, nothing short of a redesigned scheme which is based around the principles outlined in this chapter and has learned the wider lessons of the IPS model, such as the need to commission at a local level, will be able to replicate its success. The annex of this report contains three case studies of schemes based around the IPS model that are achieving positive results of people out of work because of their mental health problems.
41
Our vision for back-to-work support
In this chapter we have outlined what we think a new back-to-work scheme for people with mental health problems on ESA should look like. A scheme built around the principles described in this chapter would be far more effective at supporting people with mental health problems into work and would also help to contribute to improved health outcomes.
Recommendations
The next Government should create a new specialist scheme for people with mental health problems on ESA, designed around the following principles:
• Understanding and trust.
• Individual ambitions and aspirations.
• Specialist and person-centred support.
• Proactive engagement with employers.
• Continued support in employment.
• Integration with health and other local services.
• Focus on health outcomes as well as employment.
42
ConclusionIn this report we have described how each stage of the journey we have been looking at – from being in work, to falling out of work, to trying to move into work – is failing to properly support people with mental health problems. We have explained how a lack of understanding and misplaced assumptions about people with mental health problems undermine the whole of this journey. And we have set out the reforms that are needed to make this journey work.
This is the beginning of a vital discussion about how we:
• support more people to stay well in work
• prevent so many people falling out of work because of mental health problems
• help more people who are out of work because of their mental health to move closer to employment.
It is a process that will take time, effort and resources, but the benefits of getting it right are immense. We hope that everyone who has a role to play in this process of reform will embrace the vision we have set out, and work with us to make it a reality.
43
Client Comments
“If�I’d�been�put�under�pressure�to�apply�for�jobs,�I�wouldn’t�have�achieved�anything.”�
“�After�I�met�my�employment�specialist,�I�was�even�more�optimistic.�He�made�me�feel�confident,�really�put�me�at�ease.�I�was�comfortable�talking�to�him�about�anything.”
‘The�caring�and�compassionate�input�made�such�a�difference.”
44
Annex - Examples of effective schemes built around the IPS modelWorkplace Leeds
What is it?
Part of Leeds Mind, WorkPlace Leeds is an employment service that specialises in supporting people with a wide range of mental health problems to find and retain employment. With over 20 years of experience, they work in a friendly and supportive way, using an individually-tailored and collaborative approach to enable clients to meet their goals. Many of the people they work with have been off sick for 12 weeks or more.
The service was commissioned by NHS Leeds and Leeds City Council (Adult Social Care) in 2011, with Clinical Commissioning Groups recently funding an expansion of the job retention service.
How it works?
WorkPlace Leeds uses the IPS model, including CV building, interview skills, job search and tailored applications, as well as confidence-building, one-on-one sessions, advice on benefits, and practical assistance to overcome barriers such as childcare difficulties or public transport issues. It also offers Peer Employment Support interventions to develop confidence and a shared understanding of the struggle to get back to work.
It recognises that there are no quick fixes and the journey can be a long one, and it takes time to support clients to achieve goals such as volunteering or training along the way. Whilst work is the focus, there is a recognition of the journey to that goal.
Working in partnership
Support is delivered in partnership with mental health, social care and housing services and works closely with referrers to ensure an integrated approach. This includes partnership with the secondary mental health service, Leeds and York Partnership Foundation Trust (LYPFT), which is strengthened further through links with the Trust’s Vocational Lead practitioners. They have also worked in partnership with JCP to identify gaps in service provision.
Staff
All staff complete experiential training in resilience-building, employment specialisms and creativity in mental health. More than 50 per cent of people working at Leeds Mind have lived experience of mental health difficulties, or have cared for someone with a mental health condition.
Success rates
The annual cost to WorkPlace Leeds of supporting someone with severe and enduring mental health issues into employment is £5,819, compared to the £13,700 cost to the Work Programme of supporting an ESA claimant.
In 2013:
• 93 people gained paid employment (21 per cent)• 94 per cent of clients remained employed• 185 (48 per cent) were in training• 110 found volunteering places (28 per cent)
45
Working Well – Manchester
Built around the offer of intensive and integrated support aimed at helping individuals tackle their own barriers to work, Working Well in Greater Manchester is supporting 5,000 people who’ve been on the Work Programme for two years.
Vital to Working Well is the role of keyworkers who work one-to-one with clients and an emphasis on integration of local services. Through the use of a local integration board consisting of local employers, mental health services, drug services, housing services etc., there is an opportunity to provide ‘co-case support.’ This means the keyworker can broker in support where necessary.
Crucial to the pilot is that people can access the services they need in the right order and at the right time for them.
The pilot also focuses on wellbeing outcomes, using the Warwick Edinburgh Mental Wellbeing Scale, as well as employment outcomes to monitor its success. Whilst clients are mandated to attend their first appointment with the service, there is an emphasis on the role of the keyworker in building a relationship with the client and promoting the benefits of the support. This approach has proved successful, with keyworkers effectively promoting the benefits of the scheme to their customers, leading to high return appointments and retention rates.
Solent Mind
What is it?
Funded by Portsmouth City Council, Solent Health Trust and local IAPT services, Solent Mind offers employment advice and support to both those from secondary and primary mental health care.
How it works
The support is focused around a person-centred approach with each client seen and treated as an individual. Where the client faces external difficulties that are impacting upon their employment or them gaining employment (for example, housing problems), they aim to help solve these, or where possible signpost them to the appropriate services.
For those referred through secondary mental health services, they hold clinics in the local inpatient unit and the Adult Mental Health Service and offer advice and support in regards to job retention and exploring work, voluntary work or training upon discharge. For clients from primary health care settings they offer similar support, included attending IAPT services.
Integration
Whilst not co-located with health care services, Solent Mind uses the same patient management system as the local IAPT team, ensuring that they are able to keep up to date with clients and share information. It is this open communication and information that helps make the service so successful.
Success rates
For those referred from Primary Mental Health Services (mild to moderate):
• 20.5 per cent found new work with the help of the service• 61.4 per cent were able to retain their employment and
resolve issues they were facing at work
For those referred from Secondary Mental Health Services (severe and enduring):
• 23.8 per cent found new work with the help of the service• 19 per cent were able to retain employment and resolve
issues they were facing at work• 38 per cent engaged in a training or educational opportunity
Client comments
“�I�felt�like�it�helped�very�much�having�you there.”
“��Today�is�a�happy�day,�I’m�really�pleased�to be returning to work.”
“ I can’t tell you how invaluable your support�has�been.”
“ Thank you so much for all of your time today – I feel like I am moving forward already.”
References1 Chief Medical Officer (2013) Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence
2 OECD (2014) Mental Health and Work: United Kingdom3 Department for Work and Pensions (2014a) DWP Tabulation Tool: Employment and Support Allowance Caseload: IB ICD summary code by Payment Type
4 Chief Medical Officer (2013)5 The Equality Act 20106 See: Perkins R, Farmer P, Litchfield P (2009) Realising ambitions: Better employment support for people with a mental health condition and Catherine Hale (2014) Fulfilling Potential? ESA and the fate of the Work-Related Activity Group
7 Waddell G, Kim Burton A, (2006) Is work good for your health and well-being?
8 Butterworth P, Leach L S, Strazdins L, Oleson S C, Rodgers B, Broom D H, (2011), The psychosocial quality of work determines whether employment has benefits for mental health: results from a longitudinal national household panel survey
9 Mind (2014a) Workplace Stress Poll: YouGov survey of 1251 workers in Britain - 56 per cent said they found work very of fairly stressful, more so than debt or financial problems (38 per cent), health (29 per cent) or relationships (20 per cent)
10 Department for Work and Pensions (2001) One Evaluation
11 Shaw Trust (2010) Mental Health: Still The Last Workplace Taboo?
12 Mind (2011) Populus survey of 2,006 adults in employment
13 Waddell G, Burton A (2006)14 The Sainsbury Centre for Mental Health (2007)
Mental Health at Work: Developing the business case15 Mind (2013a)
Populus poll of 2,060 adults in England and Wales in employment
16 CIPD (2013a), Employee Outlook17 CIPD (2013b)
Absence Management Annual Survey Report18 Shaw Trust (2010) 19 BUPA (2014)
Breaking the silence: Business leaders failing those with mental health conditions (50 business leaders and 500 employees both with and without mental health conditions were independently surveyed in summer 2014)
20 Time to Change (2014) Attitudes to Mental Illness 2013 Research Report
21 Mind (2014a)22 Ibid.23 Mind (2013a)
24 Faculty of Occupational Medicine (2010) Future Direction for Occupational Healthcare in the UK. A Strategic Overview
25 Chief Medical Officer (2013) 26 We Need to Talk Coalition (2014)
Survey of over 2,000 people who have tried to access therapy in the last two years
27 Chief Medical Officer (2013) 28 Mind (2013a)29 Department for Work and Pensions (2014b)
Access to Work official statistics, July 201430 As referenced in: Perkins R, Farmer P, Litchfield P (2009)31 Disability Benefits Consortium (2014)
Big Benefits Survey 2014: of 819 people with mental health problems not currently in work, 58 per cent agreed or strongly agreed that they wanted a paid job, with only 20 per cent disagreeing, as they simply did not feel they would be able to work due to their health
Catherine Hale (2014) Of 191 people with mental health problems currently or recently receiving back-to-work support through the Work Programme or Jobcentre Plus, 61 per cent said they would want to work, with only 9 per cent saying they would not want to (the remainder being unsure)
32 Paul Litchfield (2013) An Independent Review of the Work Capability Assessment – year four
33 Catherine Hale (2014)34 Who Benefits? is a coalition campaign founded by five
charities – The Children’s Society, Crisis, Gingerbread, Mind and Macmillan Cancer Support – with the aim of giving a voice to people who need support from benefits, and the difference the support makes to their lives. For more information see www.whobenefits.co.uk
35 Who Benefits? (2014) “Second class citizens”? The personal impact of the public debate on benefits
36 Disability Benefits Consortium (2014) 587 of 727 people with mental health problems agreed or strongly agreed with the statement “The attitudes in society about welfare have made me feel ashamed of claiming the benefits I need to live my life” and 609 of 723 agreed or strongly agreed with the statement “I feel like society looks down on me because I need to claim benefits”
37 Paul Litchfield (2013)38 Work and Pensions Committee (2014)
Employment and Support Allowance and Work Capability Assessments First Report of Session 2014-15
39 Disability Benefits Consortium (2014) 2014: 368 people responded to questions on stress and worsening of mental health
40 Royal Courts of Justice (2013) MM & DM vs SSWP
46
47
41 Disability Benefits Consortium (2014) 259 of 371 people with mental health problems disagreed or strongly disagreed with the statement “they [the assessor] asked about all the symptoms/aspects of my impairment or health condition that affect my ability to work” and 217 of 371 people with mental health problems disagreed or strongly disagreed with the statement “they [the assessor] understood my impairment or health condition”
42 Professor Malcolm Harrington (2012) An Independent Review of the Work Capability Assessment – year three
43 Welfare Reform Act 2012
44 Department for Work and Pensions (2013) Evidence Based Review of the Work Capability Assessment
45 ERSA (2013) Response from ERSA to the Call for Evidence for the fourth Independent Review into the Work Capability Assessment
46 Department for Work and Pensions (2014a)
47 Statistic calculated from answer to Parliamentary Question 209801, which states 147,790 people with mental or behavioural disorders have been referred to the Work Programme, with 7,550 gaining sustained job outcomes (http://www.parliament.uk/business/publications/written-questions-answers-statements/written-question/Commons/2014-09-26/209801/) (accessed November 2014)
48 See: Work and Pensions Committee (2014) and Catherine Hale (2014)
49 See: Work and Pensions Committee (2014), Catherine Hale (2014) and Department for Work and Pensions (2012a) Work Programme evaluation: Findings from the first place of qualitative research on programme delivery
50 Department for Work and Pensions (2012b) The Work Programme: The First Year
51 Department for Work and Pensions (2014c) Work Choice: Official Statistics November 2014
52 Ibid
53 Ibid
54 Ibid
55 Department for Work and Pensions (2013) The disability and health employment strategy – the discussion so far
56 Statistic calculated from answer to Parliamentary Question 206577, on the number of Disability Employment Advisors employed by the Department of Work and Pensions in the 60 months prior to May 2014 (http://www.parliament.uk/written-questions-answers-statements/written-question/commons/2014-07-17/206577) (accessed November 2014)
57 Department for Work and Pensions (2012a)
58 Work and Pensions Committee (2013) Can the Work Programme work for all user groups
59 Catherine Hale (2014)
60 Mind (2008) In the red: debt and mental health
61 Catherine Hale (2014)
62 Department for Work and Pensions (2012a)
63 Catherine Hale (2014)
64 Mind (2014b)
Online survey of 439 people whose mental health was the
main reason for using the Work Programme or Jobcentre
Plus back-to-work support
65 Van Stolk C, Hofman J, Harner M, Janta B (2014)
Psychological Wellbeing and Work
66 Mind (2014)
“Your experience of back-to-work support”: Online Survey of
117 with mental health problems who have previously or are
currently using some form of back-to-work support
67 For information on the Public Health Outcomes Framework
see: http://www.phoutcomes.info/
For information on the Mental Health Bulletin see: http://data.
gov.uk/dataset/mental_health_bulletin
For information on the Warwick-Edinburgh Mental Wellbeing
Scale (WEMWBS) see: http://www2.warwick.ac.uk/fac/med/
research/platform/wemwbs/ or Tennant R et al., (2007) The
Warwick-Edinburgh Mental Well-being Scale (WEMWBS):
development and UK validation
68 The Centre for Mental Health (2011)
The Work Programme, supporting individuals with severe
mental health conditions into work
69 Van Stolk C, Hofman J, Harner M, Janta B, (2014)
70 Dartmouth IPS Supported Employment Center principles of
IPS, as referenced by Centre for Mental Health (http://www.
centreformentalhealth.org.uk/employment/ips.aspx) (accessed
November 2014)
71 From Rinaldi M, Miller L, Perkins R (2010)
Implementing the individual placement and support (IPS)
approach for people with mental health conditions in England;
Perkins R, Farmer P, Litchfield P (2009); Better employment
support for people with a mental health condition; Department
for Work and Pensions (2009a) A national mental health and
employment strategy; HM Government (2009), A vision for
the future of mental health services; HM Government (2009b),
A delivery plan (responding to the independent review) to
support people in contact with secondary mental health
services to be able to gain employment
Mind15-19 BroadwayStratfordLondon E15 4BQ
020 8519 [email protected]
mind.org.ukt @MindCharityf Facebook.com/mindforbettermentalhealth
Mind Infoline: 0300 123 3393
We provide advice and support to anyone experiencing a mental health problem. We campaign to improve services, raise awareness and promote understanding.
Mind’s registered charity number is 219830.